Question

Difficulty: MediumTrauma and Burns

During an amateur equestrian event, a 35-year-old woman was thrown from her horse and subsequently kicked in the left flank. She arrives at the emergency department immobilized on a backboard. She is alert but restless and complains of severe abdominal pain. Her temperature is 36.6∘C36.6^\circ\text{C} (97.9∘F97.9^\circ\text{F}), blood pressure is 82/54 mmHg82/54\text{ mmHg}, pulse is 128/min128/\text{min}, and respirations are 22/min22/\text{min}. Oxygen saturation is 97%97\% on room air. The airway is patent, and breath sounds are vesicular and symmetric bilaterally. The pelvis is mechanically stable to anteroposterior and lateral compression. The abdomen is distended, with significant ecchymosis over the left flank, and diffuse tenderness with guarding is noted. A focused assessment with sonography for trauma (FAST) demonstrates a substantial anechoic fluid collection in the hepatorenal recess (Morison's pouch) and the splenorenal recess. Intravenous access is established, and rapid infusion of 1 L of warmed crystalloid is initiated. Which of the following is the most appropriate next step in management?

  1. A
    Computed tomography scan of the abdomen and pelvis
  2. B
    Admission to the surgical intensive care unit for serial abdominal examinations
  3. Immediate exploratory laparotomyAnswer
  4. D
    Administration of intravenous piperacillin-tazobactam
  5. E
    Arterial blood gas analysis to evaluate base deficit

Answer

Immediate exploratory laparotomy
The correct answer is immediate exploratory laparotomy. This patient has sustained blunt abdominal trauma and presents with hemorrhagic shock (hypotension, tachycardia) alongside a positive FAST exam indicating intraperitoneal bleeding. The definitive treatment for a hemodynamically unstable patient with hemoperitoneum is urgent surgical exploration to identify and control the source of bleeding, such as a splenic or hepatic laceration.

Step-by-Step Solution

1
Evaluate the primary survey and hemodynamic status.
The patient is in hemorrhagic shock, evidenced by a blood pressure of 82/54 mmHg82/54\text{ mmHg} and a heart rate of 128/min128/\text{min}.
To identify immediate life-threatening physiological derangements following blunt trauma.
2
Identify the source of the hemorrhage based on clinical findings and adjuncts.
The FAST exam is positive, showing free fluid in the abdomen (hemoperitoneum), and the pelvis is stable.
To determine if the abdomen is the source of the hypovolemic shock.
3
Determine the definitive management based on the diagnostic algorithm.
Exploratory laparotomy is urgently indicated.
Hemodynamically unstable patients with a positive FAST require immediate surgical intervention for hemorrhage control.

Key Concept

Management of hemodynamically unstable blunt abdominal trauma
Estimated Time:1m 15s
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